Download A Rare Heart Rhythm Problem in Acute Rheumatic Fever: Complete

A Rare Heart Rhythm Problem in Acute Rheumatic Fever:
Complete Atrioventricular Block
Akut Romatizmal Ateşte Eşlik Eden Ender Bir Kardiyak
Ritim Bozukluğu: AV Tam Blok
Romatizmal Kardit ve Tam Kalp Bloğu / Rheumatic Carditis and Complete Heart Block
Ayse Esin Kibar1, Sevcan Erdem1, Mehmet Burhan Oflaz2,
Departments of Pediatric Cardiology, Mersin Women’s and Children’s Hospital, Mersin,
2
Departments of Pediatric Cardiology, Cumhuriyet University School of Medicine, Sivas, Turkey
1
Bu çalışma 18-21 Nisan 2012 tarihinde İzmir’de düzenlenen 11.Ulusal Kardiyoloji kongresinde poster olarak sunulmuştur.
Özet
Romatizmal kalp hastalığı çocuklarda ve genç erişkinlerde kazanılmış kalp hastalığının en önemli nedenidir. Akut Romatizmal Ateş (ARA) seyrinde farklı türlerde ritim ve ileti bozuklukları görülebilmektedir. Uzun PR aralığı ARA’da yaygın olarak görülürken tam kalp bloğu ise son derece nadir bir bulgudur. Bu makalede gezici artrarji ve hafif kardit nedeniyle ARA tanısı alan ve başvuruda tam kalp bloğu saptanan 14 yaşında kız hasta sunulmuştur. Antiinflamatuvar tedavi sonrası yatışının 3. günde 2. derece AV blok (Mobitz tip 1), 4. gününde uzun PR aralığı ile birlikte normal sinus ritmine dönüş izlendi. Romatizmal ateş seyrinde komplikasyon olarak nadiren tam kalp bloğu görünmekte ve genelde akut dönemle sınırlı seyretmektedir.
Anahtar Kelimeler
Romatizmal Ateş; Kardit; Atrioventriküler Blok; Ritim
Abstract
Rheumatic heart disease remains the most important cause of acquired heart
disease in children and young adults. Different kinds of rhythm and conduction
disturbances may be seen during the course of acute rheumatic fever (ARF). Long
PR intervals are found commonly in rheumatic fever, but complete atrioventricular (AV) block is an exceptionally rare manifestation. This case report is about a
14 year-old-female patient diagnosed as ARF based on migratory arthralgia and
mild carditis who also developed complete heart block on admission. Electrocardiogram on the 3rd day of hospitalization depicts 2nd degree atrioventricular
block (Mobitz I) combined with PR prolongation. The ECG revealed a normal sinus
rhythm with PR prolongation on the 4th day of hospitalization. Rarely, complete
AV heart block can occur as a complication of ARF and may develop during the
acute phase
Keywords
Rheumatic Fever; Carditis; Atrioventricular Block; Rhythm
DOI: 10.4328/JCAM.1185
Received: 29.06.2012 Accepted: 30.07.2012 Printed: 01.11.2015
Corresponding Author: Kibar Ayse Esin, Mersin Women’s and Children’s Hospital, Mersin, Turkey.
T.:+90 3242230701 E-Mail: [email protected]
1 | Journal of Clinical and Analytical Medicine
J Clin Anal Med 2015;6(6): 775-7
Journal of Clinical and Analytical Medicine | 775
Romatizmal Kardit ve Tam Kalp Bloğu / Rheumatic Carditis and Complete Heart Block
Introduction
Acute rheumatic fever (ARF) is a major health problem in many
countries [1]. The pathogenesis of the disease remains an enigma and specific treatment is not available. Rheumatic fever is
a multi systemic disease related to an immune reaction against
group A, Beta Streptococcus infection [2-3]. It still remains an
important cause of mortality and morbidity in our country.
Different kinds of rhythm and conduction disturbances may be
seen during the course of ARF, one of the most frequently seen
(10-75%) disorder being the first degree atrioventricular (AV)
block [1,3]. However, complete heart block is an exceptionally
rare manifestation of ARF [3]. These disturbances, mostly bradycardias, are seen independent of the valvular involvement and
they are limited to the acute phase [2,4]. Specific treatment,
such as insertion of a temporary pacemaker, should be considered only when syncope or clinical symptoms persist.
This case report is about a 14 year-old female patient diagnosed as ARF based on mild carditis and migratory arthralgia
who also complete AV block admitted to our clinic.
Case Report
A 14-year –old girl was admitted in our hospital with migratory
arthralgia of 3 days duration. She had a history of an upper
respiratory infection about 1 month before the onset of symptoms. There was no history of intake of any drugs. There was no
previous history of any joint pains.
The patient appeared ill. The body weight was 55 kg. The temperature was 36.5 oC, the blood pressure was 100/65 mm Hg
and the heart rate 75 beat per min. The cardiac examination revealed arrhythmias and grade 2 pansystolic murmur, best heard
at the apex. The findings from other examinations were normal.
The first electrocardiografic recording revealed complete AV
block with a ventricular rate of 72 beats/min (Figure 1) without
Figure 1. Electrocardiogram shows complete heart block with a ventricular rate of
72 on the day of admission.
clinical symptoms. An echocardiographic examination showed
mild mitral regurgitation (pansystolic, velocity: 3.5 m/sec) in an
otherwise structurally normal heart. The left ventricule ejection fraction was 65%. Telecardiography was normal. Laboratory studies showed the following values; white blood cell count
7180/ mm3, hemoglobin 11.5 g/dl, erythrocyte sedimentation
rate 72 mm/hr (upper limit of normal=20mm/hr), C-reactive
protein (CRP) level 2.8 mg/dl (upper limit of normal= 2 mg/dl),
antistreptolysin O (ASO) titer 1260 IU/ml (normal <320 IU/ml).
Routine biochemical investigations were normal.
The diagnosis of ARF was established according to the Jones
criteria [1]. Our patient fulfilled one major and 2 minor Jones
criteria. The presence of carditis, arthralgia, advanced AVB, elevated acute phase reactants, and high ASO titers. An intra| Journal
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muscular injection of benzathine penicillin was administered
and prednisone (40mg/day) was also provided. On the 3rd day
of hospitalization, a 24 hour Holter analysis revealed a second
degree, Mobitz type 1 AVB. On the fourth day hospitalization,
the electrocardiogram (ECG) revealed a normal sinus rhythm
with a 1st degree atrioventricular block (Figure 2). Control acute
phase reactants and ECG were also within normal ranges on
the 7th day hospitalization.. After three weeks, salicylate (3 g/
day) was also provided. After steroid and salicylate medication
was discontinued, the ECG normalized with the monthly penicillin injections. An echocardiographic examination revealed mild
mitral regurgitation in an otherwise structurally normal heart.
Figure 2. The ECG revealed a normal sinus rhythm with PR prolongation on the
4th day of hospitalization.
Discussion
Rheumatic heart disease remains the most important cause
of acquired heart disease in children and young adults [1]. The
diagnosis of RF is based on the Jones criteria [2]. Carditis is
the most serious manifestation of the rheumatic fever, since
it may cause polyarthritis, acute heart failure (pancarditis) or
culminate in chronic valvular heart disease [2,4]. Our patient
fulfilled one major and 2 minor Jones criteria and electrocardiography confirmed complete AV block. Our patient diagnosed
as ARF was made the presence of carditis, migratory arthralgia,
elevated acute phase reactants and high ASO titers , a history
of upper respiratory tract infection.
In cases with ARF, electrocardiographic abnormalities such as
sinus tachycardia, bundle branch block, nonspecific ST-T wave
changes, atrial and ventricular premature complexes and accelerated junctional rhythm can also seen with variable frequency [4-5]. However, second degree and complete heart block
is rarely manifestation of ARF [3-4]. Advanced AV block and
Stokes-Adams attacks is not frequently described and may require pacing [6]. In our case, the ECG showed complete AV block
admitted to our clinic (mean ventricular rate:72 beats/min), but
AV block has no clinical symptoms.
The carditis of ARF is considered to be pancarditis including
pericarditis, endocarditis and myocarditis. Inflammation may
affect the conduction tissue and lead to complete AV block [6].
The cause of this advanced degree AVB is uncertain, but it may
be attributed to increased vagal tone. Advanced degree AVB
with acute rheumatic fever appears to be self-limited in most
cases [3,6]. Endocardial inflammatory changes are responsible
for valvulitis, and acute rheumatic valvulitis results in chordal
elongation with prolapse of the leaflet coaptation and mitral
regurgitation. So, valvulitis can lead to permanent valvular damage [2]. It is presumed that myocardial involvement, including
the conduction pathway may be more prominent than endocarditis in our case.
Zalzstein et al [4] evaluated 65 children with ARF during period from 1994-2001 years. They showed first degree AVB in
Romatizmal Kardit ve Tam Kalp Bloğu / Rheumatic Carditis and Complete Heart Block
Romatizmal Kardit ve Tam Kalp Bloğu / Rheumatic Carditis and Complete Heart Block
72.3%, second degree AVB of Mobitz type 1 in 1.5% and the
presence of complete AVB in 4.6% cases. The disturbances of
conduction resolved in this children. Karacan et al [5] evaluated
24-hour electrocardiography of 64 children with ARF and determined mobitz type I block and atypical Wenckebach periodicity
in one patient, accelerated junctional rhythm in nine patients,
premature contractions in %29.7. Reddy et al [7] reported five
cases described of ARF with evidence of second or third degree
AVB, had range of about 2 to12 days. One patient required a
temporary pacemaker and two patients were treated with corticosteroids. Other cases found prolonged PR intervals in 84%
of 508 children with ARF, among these cases, 3 children had
complete AV block, an done patient required artificial pacing [8].
Our patients advanced AV block reverted to first degree block
with corticosteroid therapy after 3 days hospitalization and not
to required pacemaker. 24-hour electrocardiography recording
revealed episodes of 2nd degree atrioventricular block (Mobitz
1) combined with PR prolongation. Advanced block in rheumatic
fever may appear to be temporary, and resolves with conventional anti-inflammatory treatment.
As a result, in our case illustrates the course of a patient who
developed complete AV block and mild valve regurgitation. The
heart block resolved over a period of days with anti-inflammatory treatment. Different kinds of rhythm and conduction disturbances may be seen during the course of acute rheumatic
fever (ARF), but complete AV block is a very rare complication.
Competing interests
The authors declare that they have no competing interests.
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How to cite this article:
Kibar AE, Erdem S, Oflaz MB. A Rare Heart Rhythm Problem in Acute Rheumatic
Fever: Complete Atrioventricular Block. J Clin Anal Med 2015;6(6): 775-7.
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Journal of Clinical and Analytical Medicine | 777